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Differences Between Men and Women Hospitalized for Acute Heart failure
Quick Takes
- In a large international study, there continues to be sex differences in patients who present with acute heart failure.
- Women continue to be consistently under-represented in heart failure clinical trials.
- There continues to be an organized effort to reduce 30-day heart failure readmissions and post-discharge mortality.
Study Questions:
What are the clinical differences between men and women hospitalized for acute heart failure (HF)?
Methods:
In the previously published ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial, 7,141 patients were studied in an international, prospective, multicenter, randomized, double-blinded, placebo-controlled trial that examined the short- and long-term efficacy and safety of nesiritide. Patients enrolled were hospitalized for acute HF with a reduced or preserved ejection fraction (EF), who had dyspnea with minimal activity or at rest, with worsening signs of HF. Patients were randomized to treatment with nesiritide or placebo, in addition to standard therapy, within 24 hours of the first intravenous therapy for HF. Exclusion criteria included a high likelihood of being discharged from the hospital in <24 hours or life expectancy of <6 months due to a comorbid condition. Clinical endpoints included 30-day all-cause mortality or HF rehospitalization, 30-day all-cause mortality or all-cause rehospitalization, and 180-day all-cause mortality. Patient-reported endpoints were persistent dyspnea at 6 hours, 24 hours, and the EuroQOL 5 dimensions (EQ-5D) questionnaire.
Results:
Of 7,141 total patients, 4,697 (65.8%) were men and 2,444 (34.2%) were women. Women tended to be older (median 70 [59-79] vs. 65 [55-75] years) with higher systolic blood pressure (median 127 [112-140] vs. 121 [110-138] mm Hg) and better renal function (median creatinine 1.1 [0.9-1.4] vs. 1.3 [1.1-1.6] mg/dl) (all p < 0.001). Depression treated with medication was more common in women (9.6% vs. 7.0%; p < 0.001). Overall, 27% of women had preserved EF (EF >40%) as compared with 13% of men (p < 0.001). Among patients with EF ≤40%, women were less likely to receive angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (60.0% vs. 63.4%) and beta-blocker therapy (56.0% vs. 61.0%), and less likely to have an implantable cardioverter-defibrillator (17.6% vs. 22.9%) (all p < 0.03). New York Heart Association functional class and rates of cardiac resynchronization therapy were similar between men and women (all p ≥ 0.075). Signs and symptoms of HF were similar between men and women (all p > 0.05), but women experienced less in-hospital weight loss and urine output (all p < 0.01). There were no significant differences between women and men in the likelihood of dyspnea relief at 6 or 24 hours in both unadjusted and adjusted analyses. In unadjusted models, when compared with men, EQ-5D utility scores were significantly worse for women at baseline, 24 hours, discharge/day 10, and 30 days.
Conclusions:
In this trial, women experienced lower use of guideline-directed medical and device therapy for HF with reduced EF while also reporting worse health-related QOL compared with men. All be it, there were no significant sex-specific differences in post-discharge mortality or rehospitalization.
Perspective:
As we continue to focus on ways to reduce 30-day HF readmissions and post-discharge mortality, it is important to note that women continue to be under-represented in clinical trials examining impacts of acute HF. Although there was no difference in post-discharge mortality or rehospitalization when compared to men in this study, women continue to be “undertreated” in terms of guideline-directed medical therapy in HF.
Clinical Topics: Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, SCD/Ventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Angiotensin Receptor Antagonists, Angiotensin-Converting Enzyme Inhibitors, Blood Pressure, Cardiac Resynchronization Therapy, Creatinine, Defibrillators, Implantable, Depression, Dyspnea, Geriatrics, Heart Failure, Natriuretic Peptide, Brain, Patient Discharge, Patient Readmission, Quality of Life, Sex Characteristics, Stroke Volume, Treatment Outcome, Weight Loss, Women
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